Expanded Programme on Immunisation

The Expanded Programme on Immunisation) aims at reducing infant and child death and disabil- ity by preventing children from being infected with the ten major childhood vaccine preventable diseases, namely: Tuberculosis, Pertussis, Tetanus, Diphtheria, Poliomyelitis, Measles, Yellow fever, Hepatitis B, Heamophilus influenza and Pneumococcal pneumonia. The Programme also forms a solid base for the delivery of other high impact, evidence based and cost effective inter- ventions such as de-worming, LLINS, vitamin A and the promotion of Health Education mes- sages.

Provision of services in static clinics has not yielded the desired coverage for set interventions. Building staff capacity in terms of training, logistics and motivation and scaling up of services to reach people where they live and work is essential. Hard to reach communities must be targeted by the Health care delivery personnel by way of outreach activities on a weekly basis. Out-reach services include routine immunisation as well as other child survival and development interven- tions.

The target population for the EPI services in Sierra Leone includes all children under the age of one year and women of child bearing age (15-49 years).

In 2002 The EPI Programme received support from the Global Alliance for Vaccine and Immuni- sation (GAVI) for strengthening of immunisation services. Thereafter, support has been received for introduction of Yellow Fever vaccine and Pentavalent vaccine (2006). The GAVI support has facilitated an increase in immunisation coverage rate through strengthening of the cold chain sys- tem and payment of outreach allowances. Solar powered cold chain equipments are presently functional in about 80% of health facilities countrywide. As of December 2008, according to a rou- tine report, the fully immunised coverage for children under one year was 76 % compared to 2007 when it was 64%. Apart from routine immunisation and out-reach efforts at community level, sup- plemental immunisation activities, have complemented routine immunisation activities to achieve the present coverage.

A recently concluded study (2008 SLDHS) indicates that 39.8% of children age 12-23 months re- ceived all recommended vaccinations and 30.5% were vaccinated by 12 months of age. BCG coverage among children aged 12-23 months was nearly 82%. Coverage levels were also high for first DPT and Polio, 77% and 76% respectively.

The dropout rate between the first and third doses of DPT and Polio is 17% and 26% respec- tively. The proportion of children who received the measles vaccines is 60%.

The table below summarises the EPI interventions that will be carried out at the five standard lev- els of care, taking into consideration the cadre of staff available at each level.

Interventions and Services

Table 12: Expanded Programme on Immunization

Interventions and Services

Provided Community MCHP CHP/ CHC

Hospi- tal

IEC/BCC Yes Yes Yes Yes Yes Storage of vaccines No Yes Yes Yes Yes Routine and outreach

immunisation

Social mobiliza-

tion Yes Yes Yes Yes Supplemental immunisation

(and EPI plus)

Social mobiliza-

tion Yes Yes Yes Yes Mobile services to communities

outside of facility catchment areas

Social mobiliza-

tion Yes Yes Yes Yes Surveillance and case reporting

of Immunizable diseases Yes Yes Yes Yes Yes Reporting immunisation

activities Yes Yes Yes Yes Yes Supervision of EPI activities Yes Yes Yes Yes Yes

7.7 Integrated Management of Infant and Childhood Illness

The Integrated Management of Childhood Illness is a strategy that addresses all the main causes of childhood illnesses and death, recognizes that a child may actually be sick with more than one problem at the same time, and ensures that the occasion of a sickness consultation is not a missed opportunity to immunize the child or address a nutrition problem.

By observing specific symptoms or signs, a caretaker or health worker can distinguish between mild, moderate and severe illness in the child, and the health system is organized to manage each level of severity in appropriate ways.

The first and most important role is that of the caretaker recognizing that the child is sick and knowing when and where to go.

Teaching these skills to caretakers is one of the most important tasks of CHWs in the community. CHWs themselves should be taught to manage diarrhoea with some dehydration with both Oral Rehydration Therapy (using the low osmolarity salts) and the 14 day course of zinc tablets, which will reduce both the length and severity of the illness as well as provide some protection against

Also important is an ORS corner or a place where the mother can be taught to give the ORT or medicine, learn when she should return for a check up and learn to recognize the danger signs which mean that the child needs extra attention.

Community Health Centres and district hospitals will have the staff and facilities to care for chil- dren with severe illness. This will usually involve admission for a few days to provide regular par- enteral medication and necessary nursing care and help with diet and fluids.

One of the situations where valuable time is lost in caring for a very sick child is when the child is referred to a facility and both child and mother get lost in a long queue of mothers and children, most of whom do not need such urgent care. In busy hospital outpatient clinics, it is essential that a system of emergency triage of waiting children should identify those that are very sick and re- quire urgent attention.

The table below summarises the IMCI interventions that will be carried out at the five standard levels of care taking into considerations the cadre of staff available at each level.

Table 13: Integrated Management of Infant and Childhood Illness

Interventions and Services Provided

Community

MCHP CHP CHC Hospital

IEC/BCC on home care for the sick child, danger signs, completing treatment and

YES Yes** Yes Yes Yes Management of severely ill

child NO.* YES** Yes Yes Yes Emergency triage assess-

ment and treatment -NO Yes ** Yes Yes Yes

Cough or cold YES* YES**

Teach home care & danger signs Teach home care & danger signs Teach home care & danger signs Pneumonia NO Yes Yes Yes Yes Severe Pneumonia Refer First aid

and refer Yes Yes Yes Ear infection No Yes Yes Yes Yes Diarrhoea with no

dehydration

Teach home care & dan-

ger signs

Yes Yes Yes Yes Diarrhoea with some

dehydration No* Yes Yes Yes Yes Diarrhoea with severe

dehydration No*

First aid &

refer Yes Yes Yes Persistent diarrhoea

or dysentery No* No** Yes Yes Yes

Interventions and Services

Interventions and Services

Provided Community MCHP CHP CHC Hospital

Measles No Yes Yes Yes Yes Complicated measles No No** Yes Yes Yes Case management of child

with fever/malaria Yes Yes Yes Yes Yes Management of severe mal-

nutrition with complications Yes** Yes** Yes** Yes** Yes Management of severe mal-

nutrition without complica- tions (Investigation and feed-

Yes** Yes Yes Yes Yes

*Recognise danger signs for urgent referral

** Give first dose of antimalarials/ antibiotic & refer urgently

7.8 Infant and young child nutrition

Nutritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Poor nutritional status is one of the most important health and welfare problems facing Sierra Leone today and affects the most vulnerable groups: women and children. At the individual level, inadequate or inappropriate feeding patterns lead to malnutrition. Infant and young child nutrition is an important but complex issue to address. Prevention of under -nutrition starts with the prevention of low birth weight by means of appropriate diet for the preg- nant woman, avoidance of hard work in the third trimester, and prevention of malaria which im- proves placental function by intermittent preventive treatment in the second and third trimesters. Women are encouraged to initiate breastfeeding within the first 30 minutes after birth.

Growth monitoring is one of the key child survival strategies which help the health worker to iden- tify children who are becoming malnourished, investigate the cause and take necessary action to prevent further deterioration. It must be encouraged at all levels.

Interventions and Services

Table 14: Infant and young child nutrition Interventions and Services

Provided Community MCHP CHP CHC Hospital

Child Nutrition

For pregnant women, Intermittent Pre- ventive Treatment (IPT) of malaria to reduce incidence of low birth weight.

** Yes Yes Yes Yes

Promotion of early breast feeding and exclusive breast feeding for the first six months

Yes Yes Yes Yes Yes

Promotion of appropriate complemen-

tary feeding Yes Yes Yes Yes Yes

Growth monitoring and nutrition

counselling - Yes Yes * Yes * Yes *

Vitamin supplementation to children 6

-59 months * * Yes Yes Yes Yes

Identification of malnutrition Yes Yes

Yes (W/A)

Yes (W/

A) Yes (W/A)

Investigation & management of se-

vere malnutrition Ref Ref Ref Ref Yes

* * Micronutrients and de-worming medicines are not normally distributed to children and preg- nant women by community health workers, but this can be done by them very effectively and reliably. Such a program needs to be carefully planned, implemented and supervised with attention to recording on the mother or child's care card.

Almost all (95%) of children under six months in Sierra Leone are breastfed and at age 12 to 15 months are still breast fed. Exclusive breast feeding is however not common. Only 11% of chil- dren less than 6 months are exclusively breast fed (DHS 2008).

For young children, the objective is to change social norms to promote exclusive breast feeding in the first six months, followed by introduction of adequate complementary foods at the necessary frequency during the day. The IMCI complements growth monitoring and promotion because it tells the health worker the specific action to take when a child’s faltering growth is found to be re- lated to any of the childhood illnesses. Growth monitoring is very important from 6-24 months when a child is being introduced to other foods in addition to breast milk because it tells whether the child is getting enough food and the right type to enable him or her grow well.

Interventions and Services